Basic Information
| Provider Information | |||||||||
| NPI: | 1538244389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOODMAN | ||||||||
| FirstName: | JORDAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 REMINGTON BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 6309142469 | ||||||||
| Practice Location | |||||||||
| Address1: | 656 N CONVENT ST STE B | ||||||||
| Address2: | |||||||||
| City: | BOURBONNAIS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 609141393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159365186 | ||||||||
| FaxNumber: | 8159365190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2006 | ||||||||
| LastUpdateDate: | 08/08/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-081034 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.